Chapter 3 Introduction to the Uniform Hospital Discharge Data Set and Official ICD-10-CM Coding Guidelines

Not elsewhere classified

When a specific code is not available for a condition the alphabetic index directs the coder to the other specified code in tabular list.

Other or other specified" codes

Codes titled "Other or other specified" are for use when the information in the medical record provides detailed for which a specific code does not exist.

Unspecified" codes

Codes titled "Unspecified" are for use when the information in the medical records is insufficient to assign a more specific code.

Excludes 1

Not Coded Here" Notes indicates that the code excluded should never be used at the same time as the code above the excludes 1 note.

Excludes 2

Not included here" Note includes that the condition excluded is not part of the condition represented by the code, but a patient might have both conditions.

In diseases classified elsewhere

Never permitted to be used as first- listed or principal diagnosis code.


Report when a related definitive diagnosis has not been established or confirmed by the provider.

Acute and Chronic Conditions

If the same condition is described as both acute (subacute) and chronic, and separate subentried exist code both and sequence the acute first.

Sequelae (late effects)

A residual effect (condition produced) after the acute phase of an illness or injury has terminated.

Reporting same diagnosis code more than once

Only report code once if no distinct codes identifying laterality.

Complication of Care

There must be a cause and effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication.

Borderline Diagnosis

If the provider documents a "borderline" diagnosis at the time of discharge, the diagnosis is Coded as confirmed, unless the classification provides an specific entry.

Use sign/Symptoms and unspecified Codes

Each healthcare encounter should be Coded to the level of certainty known for that encounter.

Admitted for treatment and develop complication

Code treatment then code complication.


Preexisting condition that because of its presence with a specific principle diagnosis will likely cause an increase in the patients length of stay in hospital


Additional diagnosis that describes a condition arising after the beginning of hospital observation and treatment and then modifying the course of patients illness or medical care required

Principle procedure

This type of procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes or when it is necessary to take care of a complication if two procedures appear to be this the one most related to principle diagnosis should b

Principle diagnosis

Is designated and defined as the condition established after study to be chiefly responsible for occasioning the admission of patient to hospital of care


All affecting the current hospital stay must be reported as part of uhdds

Other diagnosis

Theses are designated and defined as all conditions that coexist at the time of admission that develop subsequently or that affect the treatment

Disposition of patient

The destination of patient upon leaving the hospital -- discharge to home, left against medical advice, discharged to another short term or long term institution, died or other

Expected payer

The single major source expected by patient to pay for bill Medicare Medicaid Billie cross shield etc

Hospital identification

The unique number assigned to each institution

Personal identification

The unquie number assigned to each patient that distinguishes the patient and their health record from others

Physician identication

The unique number assigned to each physician within the hospital (attending physician and operation physician if applicable are both identified

Significant procedure

Is of surgical nature
Carries a procedural risk
Carries an anesthetic risk
Requires specialized training

National uniform billing committee NUBC

Established with a goal of developing an acceptable uniform bill that would consolidated the numerous billing forms hospitals and other institutions were required to use

Present on admission

Indicator is to differentiate between conditions present at admission and conditions that develop during inpatient admission

Uniform hospital discharge data set uhdds

It sought to improve the uniformity and comparability of hospital discharge data

What was the purpose of developing the UHDDS?

improve the uniformity and comparability of hospital discharge data

When determining what "other diagnoses" should be coded & reported for an inpatient encounter the condition must affect the patient's care in terms of requiring one of the following

:*clinical evaluation
*therapeutic treatment
*diagnostic procedures
*extended LOS
*increased nursing care or monitoring

uncertain diagnoses are only coded for.

.inpatient services

how first listed diagnosis is determined when patient has outpatient surgery?

code diagnosis for which the surgery is being performed as first listed diagnosis even if surgery was discontinued

how first listed diagnosis is determined when patient is in observation stay?

assign the medical condition for the stay as the first listed diagnosis

if patient comes for surgery and develops complications requiring admission to observation..

reason for surgery was to be performed
complications as secondary

The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. what does "after study" mean?

condition determined after evaluation of findings

In the case of a final inpatient discharge diagnosis documented as "rule out", the guidelines direct us to:

code the condition as if it existed or was established

a patient complains of nausea and abdominal pain and undergoes an EGD for suspected hiatal hernia. The EGD was negative, so the physician instructed the patient to return next week to be tested for reflux. Based on outpatient guidelines, which of the foll

nausea and abdominal pain

what standardizes inpatient data elements for reporting purposes and do not apply to outpatients?

UHDDS definitions and guidelines

for an outpatient visit, when a definitive diagnosis has not been determined by the provider, what should be coded?

signs and symptoms

outpatient diagnostic coding differs from inpatient coding in which two significant ways?

*definition of first listed diagnosis and principal diagnosis
*definition of principal diagnosis and coding of inconclusive diagnoses
*definitions of encounter and admission

in the outpatient setting, when the physician's final diagnosis is documented with the term "probable" based on diagnostic workup and initial therapeutic approach that are consistent with the diagnosis, which of the following two options is correct?

code the condition to the highest degree of certainty for that encounter, such as symptoms, signs, abnormal test results or other reason for the visit

when a definitive diagnosis is available symptoms can or can not be coded?

can not

UHDDS promulgated by us department of health, education, welfare in _______ as a minimum common core of data on individual acute care short term hospital discharges in Medicare and Medicaid programs.


How is the individual patient identified according to the data elements in the UHDDS?

The patient is identified by a unique number assigned to each patient that distinguishes the patient and his or her health record from all others. Other identifying information is the patient's date of birth, sex, race, and ethnicity. The patient's reside

How does the coder determine if a procedure is significant to code?

A coder should identify if the procedure was surgical in nature, carries a potential risk, carries an anesthetic risk or requires specialized training to help them code for significant procedures. Nonsignificant procedures are usually not coded.

What is the difference between the admitting diagnosis, the principle diagnosis, and the most significant diagnosis?

The admitting diagnosis may be a symptom or ill-defined condition with which the patient presents. The principle diagnosis is the condition established after study to be chiefly responsible for occasioning the admission. The most significant diagnosis is

What is the UHDDS definition of "Other Diagnoses"?

all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be exclude

According to Guideline III.C can uncertain diagnoses be reported as additional diagnosis?

Yes, if the additional diagnosis documented at the time of discharge is qualified as "probable," "suspected," "likely," "questionable," "possible," or "still to be ruled out," "compatible with," "consistent with," or other similar terms indicating uncerta

According to Guideline IV,G what should be listed as the first diagnosis code for the outpatient visit?

List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided

What parties are responsible for developing and maintaining ICD-10-CM?

The American Hospital Association, the American Health Information Management Association, the Centers for Medicare & Medicaid Services, and the Centers for Disease Control and Prevention's National Center for Health Statistics

after study

admitting diagnosis has to be worked up through diagnostic tests and studies.

Coding Conventions VS Coding Guidelines

conventions take precedence over guidelines

When there are two or more in a related conditions potentially meeting the definition of principal diagnosis..

Either condition may be sequence first, unless the circumstances of the admission, the therapy provided, the Tabular List, or Alphabetic Index indicates otherwise

history codes may be used as secondary codes if..

The historical condition or family history has an impact on current care or influences treatment

Hospital Discharge